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Racial discrimination in health care: An “us” problem

2020; Wiley; Volume: 29; Issue: 23-24 Linguagem: Inglês

10.1111/jocn.15449

1365-2702

Diana Baptiste, Nia Josiah, Kamila A. Alexander, Yvonne Commodore‐Mensah, Patty Wilson, Keilah Jacques, Debra Jackson,

Global Health Workforce Issues

If we accept and acquiesce in the face of discrimination, we accept the responsibility ourselves and allow those responsible to salve their conscience by believing that they have our acceptance and concurrence. We should, therefore, protest openly everything… that smacks of discrimination or slander. Mary McLeod Bethune Since the killings of Black Americans George Floyd and Breonna Taylor by law enforcement officers, social conversations about race have shifted from evasive dialogue to unvarnished discourse. Race relations, often-coined euphemisms for white supremacy, are no longer masked as "pink elephants in the room." Racial disparities, an exigent dilemma in the United States, are ongoing and endemic. Racism is not just a public health issue, but also a humanitarian crisis! Racism is defined as "prejudice, discrimination, or antagonism directed against a person or people on the basis of their membership in a particular racial or ethnic group, typically one that is a minority or marginalized" (Dictionary, 2020). Racism is systemic. When it is systemic, it is ingrained in a culture and becomes implicit (Feagin & Bennefield, 2014). Feagin and Bennefield (2014:7) observe that "from the 1600s, the oppression of Americans of colour has been systemic and rationalised using a white racial framing—with its constituent racist stereotypes, ideologies, images, narratives and emotions." Subsequently, there are concerns that a public health crisis such as coronavirus disease 2019 (COVID-19) colliding with protests for racial justice can exacerbate discrimination, racism and stigma due to widespread disinformation; similarly demonstrated in the treatment of people with HIV in the 1980s (Devakumar, Shannon, Bhopal, & Abubakar, 2020; Williams & Cooper, 2020). Racism, defined in a theoretical framework by Dr. Camara Phyllis Jones (2000), is described at three levels: institutionalised, personally mediated and internalised. Dr. Jones' framework alludes to understanding levels of racism using a gardening metaphor. She likens institutionalised racism it to planting a single seed packet into two boxes, one box having new rich potting soil and the other with poor, rocky soil. As a result, the seeds sown in into the rich new soil flourish and sprout up quickly, while the seeds planted in the poor soil grow weakly, with many not surviving. Internalised and personalised racism reflects societal values, maintenance of structural barriers and complicity with systems of privilege. In this Gardener's Tale, personalised racism is illustrated as a preference for red flowers over pink flowers, where the gardener allows the red flowers to grow and plucks the less desired pink flowers out of the soil before they have a chance to flourish. Internalised racism is represented by the bees as the preference of pollinating the red flower over the pink flowers. This analogy offers an illustration of the importance of fostering an environment of growth and equity (Jones, 2000). In the Gardener's Tale, Jones offers the solution of either changing the gardener or breaking down both boxes to mix the soil, or just adding fertiliser to the poor soil to cultivate strength and beauty among both red and pink flowers. Like the gardener in the Gardener's Tale, nurses can play a pivotal role in enriching the soil (healthcare systems) that foster healthy environments to produce vibrant flowers (patients, families and communities) in all colours. As nurses, we see first-hand the impact that systemic racism continues to have on health and well-being. However, it is questionable whether healthcare providers deny or dismiss the existence of racial inequities in their own clinical settings. For healthcare providers to become partners in eradicating racial discrimination in health care, we must first acknowledge and understand the existence of racial discrimination. Contemporary reviews of literature on discrimination in health professional practices further illustrate the role of stigma and bias in disproportionate rates of death on early onset of disease in African Americans. These unjust outcomes are due to racial fetage—a term used by David R. Williams and other health equity scholars also commonly referred to as weathering (Feagin & Bennefield, 2014; Geronimus, 1996). The presence of anti-Black stigma and bias is presented in the social behaviours of healthcare practitioners, leading to inequity in healthcare access and quality of care (FitzGerald & Hurst, 2017; Krieger, 2014). Historically, Black, Indigenous and people of colour (BIPOC) are consistently marginalised within healthcare systems due to lack of access, inadequate treatment and racial discrimination. These grave disparities affect Black Americans at alarming rates. It is well known that Black Americans are disproportionately affected by leading causes of death, including heart disease, stroke, cancer, kidney disease and hypertension compared to White Americans (Havranek et al., 2015; Yancy, 2020). BIPOC communities have also been disproportionately impacted by the current COVID-19 pandemic with higher mortality rates than White Americans (Baptiste et al., 2020; Yancy, 2020). A prime example of the structural and systemic racism within the U.S. healthcare systems is evidenced by the high maternal mortality rates among Black women. Black women are 3–4 times more likely to die while giving birth than white women in the United States (Howell, 2018; Prevention, 2017). More glaringly, over half of maternal deaths occur in the postpartum period, one-third occurring within a week after delivery (Howell, 2018). Several studies have explored the possibility of social determinants such as poverty, education and geographical location as risk factors. However, studies have shown that it is discrimination by race, and not social determinants, that influence whether a mother dies while childbearing or not (Howell, 2018; Vedam et al., 2019). Astounding as it seems, this is our reality, "An 'us' problem!" The excess maternal mortality has everything to do with blatant contempt and maltreatment of Black populations within the childbearing setting. The authors have witnessed discriminatory language often used for referencing Black males in obstetric wards, with healthcare providers referring to Black fathers as the "baby daddies" while respectfully referring to White fathers as partners and husbands. The derogatory term Baby Daddy comes from an urban myth perpetuated to describe a disengaged male recklessly impregnating multiple women (Izrael, 2011). A study by Vedam et al. (2019) reported that White women with Black partners are more likely to experience mistreatment from healthcare providers in comparison to White women with White partners. While stigmatising Black fathers, there is a general assumption that the White father is immediately perceived as a responsible partner. This is unfair. The overt disparage of Black fathers has a rippling effect and transfers over the care of the mother and infant. Furthermore, the main culprit leading to adverse health outcomes in Black maternal populations is chronic stress. Stress from exposure to discrimination intersecting race and gender, as well as trauma across the lifespan "weathering," contributes to Black maternal populations' poorer birth outcomes (Geronimus, 1996). Preconception risk factors such as obesity, diabetes, hypertension, alcohol intake and smoking also lead to adverse maternal outcomes. A recent study examining preconception risk factors discovered Black women have the highest rates of obesity compared to any other ethnic group (Howell, 2018). Black women also face financial barriers to health care at a disproportionate rate. When compared to white women, Black women are more likely to be uninsured, lacking access to prenatal care (Chambers et al., 2020; Howell, 2018). When Black women do receive care, the quality of care is often sub-par; as they are more likely to experience lower-quality communication from healthcare providers, less involvement in decision-making and have higher chances of experiencing racial discrimination during healthcare encounters (Attanasio & Hardeman, 2019). In 2017, National Public Radio (NPR) collected over 200 stories of African American mothers reporting feelings of devalue or disrespect by healthcare providers (Martin & Montagne, 2017). One featured story was about Black mother, Dr. Shalon Irving, an Epidemiologist at the Centers for Disease Control and Prevention who passed away at the age of 36 from postpartum complications. Irving had experienced a host of maladies including traumatic life events resulting in chronic stress, uterine fibroids, obesity, blood clotting disease and hypertension. She worked hard to suppress her emotions and pain for fear of discrimination. Her silence stemmed from anticipation of healthcare system biases and the avoidance of being stereotyped as an "angry Black woman" to the detriment of her own health (Attanasio & Hardeman, 2019; Martin & Montagne, 2017). When she finally reported her cascade of postpartum complications, providers overlooked her concerns reassuring—"Oh, that is to be expected." Sadly, neglect ultimately led to Irving's sudden and untimely death (Martin & Montagne, 2017). Her education and prestige were neither enough to protect her nor enough to ensure her survival. Likewise, legendary Black tennis player Serena Williams publicly shared her accounts of not being listened to while giving birth to her daughter. Serena relentlessly tried to forewarn healthcare professionals about her pre-existing clotting condition with no avail (Rabin, 2019; Salam, 2018). Consequently, her accounts were dismissed, putting herself and her unborn child at risk for severe complications. Childbearing Black women are not only dying from complications; they are dying from stigma and assumptions from healthcare providers that their requests for assistance do not warrant certain timely treatment measures (Vedam et al., 2019). The American healthcare system inarguably fails Black people. The desperate bellows of pain belted out from Black men, women and children go often ignored. Again, this is our reality, "An 'us' problem!" The focus of this discussion is not to bring negative attention to the nursing profession or healthcare systems, but to call attention to the "pink elephant in the room" that needs to be addressed head on among healthcare professionals. To tackle the concerns of exacerbations, significant efforts must be made to address health inequities due to racism and xenophobia. Yet addressing underlying social inequities and healthcare access requires a long-term investment in transforming values, laws and policies. This is an "us" problem as there is a clear disconnect within healthcare systems and among those who receive nonbiased care. The values of diversity, equity and inclusion are found under the mission and values statements of about every health organisation. In 2018, the American Nurses Association (ANA) released their latest position statement, The Nurses Role in Addressing Discrimination: Protecting and Promoting Inclusive Strategies in Practice Settings, Policy and Advocacy, a national effort to eliminate discrimination associated with race, gender, socioeconomic status, access to and quality of health care (Association, 2018). Nurses are taught to uphold these standards; however, there are gaps in the application to nursing practice. The ANA further states, "Nursing can be described as both an art and a science; a heart and a mind. At its heart, lies a fundamental respect for human dignity and an intuition for a patient's needs [ensuring] that every patient, from city hospital to community health center; state prison to summer camp, receives the best possible care regardless of who they are, or where they may be." (Association,n.d. para 3). Nurses are privileged with opportunities to work with patients and families from unique backgrounds, with differences in race, identified gender, country of origin, languages, sexual orientation, among others, and must honour and embrace these differences. The provision of nondiscriminatory and equitable care is the responsibility of all nurses. The Black Lives Matter movement provides all nurses everywhere with the catalyst to critically reflect our own interactions, responses and advocacy for BIPOC clients, patients, colleagues, friends, family and communities. Every nurse everywhere has a role to play in challenging racism and contributing to a world that is equitable and safe for all people, of all backgrounds, on all occasions. As nurses, we say, Black Lives Matter. Authors report no conflict of interest.